Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Urinary Incontinence in Women


Related Terms

  • Functional Incontinence
  • Mixed Incontinence
  • Motor Urge Incontinence
  • Overactive Bladder Syndrome
  • Overflow Incontinence
  • Sensory Urge Incontinence
  • Stress Incontinence
  • Total Urinary Incontinence
  • Unstable Bladder
  • Urge Incontinence

Differential Diagnosis

  • Congestive heart failure (CHF)
  • Neurologic conditions
  • Pyelonephritis
  • Stool impaction
  • Stroke (infarction)
  • Urinary tract infection
  • Uterine prolapse
  • Vaginal/urethral discharge

Specialists

  • Gynecologist
  • Internal Medicine Physician
  • Neurologist
  • Urologist

Comorbid Conditions

  • Congestive heart failure (CHF)
  • Diabetes mellitus
  • Neurologic conditions
  • Obesity
  • Psychiatric conditions
  • Stool impaction
  • Urinary tract infection

Factors Influencing Duration

The type of underlying disorder, the woman's age, whether she is obese and / or has diabetes, the type of incontinence and nature of applied therapy, the woman's response to treatment, any complications of reconstructive surgery, and job requirements, may influence length of disability.

Medical Codes

ICD-9-CM:
625.6 - Stress Incontinence, Female
788.30 - Symptoms Involving Urinary System, Urinary Incontinence, Unspecified; Enuresis NOS
788.31 - Symptoms Involving Urinary System, Urge Incontinence
788.33 - Symptoms Involving Urinary System, Mixed Incontinence (Female) (Male); Urge and Stress
788.34 - Symptoms Involving Urinary System, Incontinence without Sensory Awareness
788.35 - Symptoms Involving Urinary System, Urinary Incontinence with Post-void Dribbling
788.36 - Symptoms Involving Urinary System, Urinary Incontinence with Nocturnal Enuresis
788.37 - Symptoms Involving Urinary System, Urinary Incontinence with Continuous Leakage
788.38 - Symptoms Involving Urinary System, Urinary Incontinence, Overflow Incontinence
788.39 - Symptoms Involving Urinary System, Urinary Incontinence, Other

Overview

Urinary incontinence is the involuntary loss of urine. There are several types of urinary incontinence, which have multiple and varying causes. Nevertheless, there is a great deal of overlap in the conditions, with the result that one cause may be a factor in more than one type of urinary incontinence.

Stress incontinence results in leakage of small amounts of urine during moments of increased intra-abdominal pressure during physical exertion such as coughing, sneezing, jumping, lifting, or changing position. It also can occur when there is diminished urethral sphincter function from previous pelvic surgeries.

Urge incontinence, sometimes called an unstable bladder (overactive bladder syndrome), results from an abnormal contraction of the bladder muscle (detrusor muscle). It is not related to position or activity. The woman feels the strong need to urinate and is unable to suppress the urge enough to prevent the flow of urine. A large amount of urine can be lost and under very unpredictable circumstances.

Mixed incontinence occurs when there is a combination of stress and urge incontinence, where the pelvic floor muscles are weak or urethral sphincter function is diminished and the detrusor muscle is overactive.

Overflow incontinence is seen with a chronically distended bladder that never fully empties, resulting in frequent leakage of small amounts of urine. This situation may be due to a disorder of the nerves that supply the bladder (as in diabetes) or a partial obstruction to bladder emptying causing urethral narrowing.

Total urinary incontinence is seen when the urethra provides no resistance to the flow of urine. The bladder is unable to store urine, allowing the continuous leak of urine. This can occur with anatomic abnormalities, trauma, or congenital defects.

Functional incontinence is not related to abnormalities in the urinary tract; other factors cause the incontinence. Physical limitations on mobility may prevent appropriate bladder emptying. Severe mental impairment or delirium can reduce an individual's understanding that incontinence is not desirable or appropriate. Medications and infections also may play a role in causing functional incontinence.

Hypotonic neurogenic bladder, due to nervous system damage, also may be a cause of urinary incontinence.

Incidence and Prevalence: Urinary incontinence affects 13 million adults in the US, the majority of which are women. Prevalence of female stress incontinence in whites is 41%, blacks 20%, and Hispanics 36% (Vasavada).

Urinary incontinence increases with age. It is found in 6.9% in women aged 20 to 39, 17.2% in women aged 40 to 59, 23.3% in women aged 60 to 79, and 31.7% of women older than age 80 (Nygaard).

In women younger than age 65, stress incontinence is the most common form of urinary incontinence; after age 65, mixed incontinence is the most common form (O’Shaughnessy). Across all ages, women are twice as likely to experience incontinence as men (O’Shaughnessy).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Risk for urinary incontinence increases with age, female gender, decrease in estrogen levels at menopause, obesity, smoking, chronic constipation, connective tissue disorders, multiple sclerosis, Parkinson's disease, diabetes mellitus, certain medications, a history of urinary tract infections or kidney stones, and a history of pelvic surgeries.

A woman who is pregnant or who experiences tears between the vagina and rectum (perineal tears) during delivery, who has a prolonged and difficult delivery, or who has had a hysterectomy is also more at risk.

Source: Medical Disability Advisor



Diagnosis

History: With stress incontinence, a woman may report loss of a small amount of urine with sneezing, coughing, laughing, bending, lifting weight, or rising from a sitting to standing position. She also may report the sensation of heaviness in the pelvic area but typically can control unwanted urination at night.

With urge incontinence, a woman may report a strong urge to urinate, loss of a large amount of urine, frequent voiding with the urge to urinate coming too fast to get to the toilet, or the loss of urine at the sound of running water. The women may report episodes of urgent nighttime urination.

With mixed incontinence, a woman may report symptoms of both stress and urge types of incontinence.

In overflow incontinence, there is a report of dribbling urine without being aware of urine loss and the sensation of incomplete emptying of the bladder.

In functional incontinence, the woman may or may not complain of loss of urine, depending on the cause of the functional incontinence. If the woman is physically disabled, she may report being unable to reach a toilet in time or having adequate assistance in getting on the toilet. The woman may report incontinence from taking certain medications. A caregiver may be the person who reports incontinence in women with delirium or dementia. Women also may report incontinence of urine with chronic constipation.

A woman may report neurologic conditions affecting the bladder and urinary sphincter, such as spinal cord injury, stroke, diabetes, Parkinson's disease, or multiple sclerosis. She may relay a history of trauma, vaginal surgery, extensive rectal surgery using an incision in the abdomen and perineum, removal of the uterus (radical hysterectomy), radiation therapy, or previous surgical repair for incontinence.
The woman may be asked to keep a voiding diary that notes instances of normal and abnormal voiding and includes information such as timing (day or nighttime), onset, duration, frequency, the timing of medications, possible precipitating events, the presence of blood in the urine, and an estimate of the amount of urine lost.

Physical exam: Abnormalities such as a pouch-like protrusion of the urethra into the vagina (urethrocele), pouch-like protrusion of the bladder into the vagina (cystocele), a hernia that protrudes through the rectovaginal pouch (enterocele), or a pouch-like protrusion of the rectum into the back wall of the vagina (rectocele) may be revealed. Other abnormal findings may include redness, vaginal or urethral discharge, tissue shrinkage (atrophy), or lax vaginal muscles. A pelvic examination is performed with a full and empty bladder and during coughing or straining, to check for incontinence and sagging of the urethra (prolapse). A thorough neurological exam is helpful.

Tests: Tests may include a urinalysis and urine culture to test for bacterial infection. Blood tests to screen for diabetes may be performed. The pad test may be employed to measure involuntary urine loss. Urodynamic testing often is performed, including measurements of bladder capacity, urethral mobility, sensation, pressures within the bladder when full of urine, pressure changes that occur during urination, voluntary control, and pressure in the urethra (cystometry and urethral pressure profile).

Visual inspection of the bladder with fiberoptic video cameras (cystoscopy and urethroscopy) may be performed. MRI may be helpful in visualizing the pelvic floor. Electromyography (EMG) can be helpful for evaluating sphincter and pelvic floor muscle strength. An ultrasound of the kidneys may rule out abnormal accumulation of fluid in the kidneys and help measure the post-void residual volume (PVR) of urine in the bladder. If there is blood in the urine, an intravenous pyelogram (IVP) and cystourethroscopy can help to determine its source.

Source: Medical Disability Advisor



Treatment

Effective treatment requires a correct diagnosis of the cause of incontinence. Any predisposing conditions should be treated first, such as a chronic cough, urinary tract infection, or constipation.

The treatment of stress, urge, or mixed incontinence may require exercises to strengthen the pelvic floor (Kegel exercises), resisted exercises using vaginal weights, biofeedback, electrical stimulation of the pelvic floor muscles, bladder training education, behavioral therapy, drugs, or surgery.

Surgical procedures for stress incontinence include repair of cystocele and bladder neck suspension procedures. There are a variety of bladder neck suspension procedures involving either an abdominal or vaginal approach, and the procedure may be performed laparoscopically to repair the urethra. A pubovaginal sling (placement of an artificial sphincter) and periurethral bulking injections may be applied to compress the urethra and increase resistance to urine leakage.

The treatment of urge incontinence also may include antibiotic therapy, topical estrogen therapy, or removal of bladder stones or tumors, if present. If unstable bladder muscles cause urge incontinence, antispasmodic or anticholinergic medications may be beneficial to inhibit involuntary bladder contractions and increase bladder capacity. In some cases, an implantable sacral nerve-stimulating device may be implanted to activate inhibitory spinal pathways; this is successful in nearly 50% of cases (O’Shaughnessy).

In the case of overflow incontinence, the cause of incomplete bladder emptying must be surgically removed or corrected if possible. Alpha-blockers therapy, avoidance of anticholinergic drugs, intermittent draining of the bladder with a catheter, or permanent bladder drainage (suprapubic catheterization) may be recommended. If overflow incontinence is related to neurological diseases, then bladder and bowel training, techniques to assist bladder emptying, urinating according to a schedule, management of fluid intake, and improvements to aide mobility may be employed.

The treatment of functional incontinence may include a number of different approaches. Functional incontinence that is related to sleeping pills, diuretics, or alcohol requires restriction or avoidance of the offending substance. Anticholinergic drugs should be avoided. If incontinence is related to sensory deficits, an inability to remove clothing quickly or easily, or restricted access to the toilet, aids such as easy-to-remove clothing, assistive walking devices, and convenient toilet facilities should be provided. If incontinence is related to dementia or mental deficits, assisting the individual to the toilet at regularly scheduled times may be attempted.

Relieving the impaction treats incontinence due to stool impaction. If incontinence is related to lack of estrogen, medication with estrogen may be recommended. Urinary tract infections causing incontinence are treated with antibiotics. Antidepressants may be effective for mixed etiologies of urinary incontinence.

Source: Medical Disability Advisor



Prognosis

The outcome depends on successful treatment of the underlying condition or cause of the incontinence. Up to 87% of women with stress incontinence can be significantly helped, with Kegel exercises and electrical stimulation to the pelvic floor; surgery relieves symptoms in 88% of cases (Ogundele). Urge incontinence and overflow incontinence are more likely to recur or become a chronic condition. In individuals with urge incontinence, bladder training helps in 75% of cases, whereas anticholinergic medications help in 44% of cases (Ogundele).

Treatment of urinary tract infection should relieve all symptoms of incontinence caused by bacterial infection. Removal of stones from the bladder or urethra should relieve all symptoms of incontinence caused by obstruction.

Incontinence due to dementia and mental health disorders may continue unless there is resolution of the underlying condition.

Source: Medical Disability Advisor



Rehabilitation

Rehabilitation procedures such as Kegel exercises, electrical stimulation to the pelvic floor, and bladder training programs may be used in the treatment of incontinence. Kegel exercises involve tightening the muscles in the pelvis that are used to control urination, and then relaxing them. This is repeated many times a day, in order to build up the strength of muscles in the urethral area. Weighted vaginal cones may also increase pelvic floor muscle strength, and are retained for 15 minutes, twice a day with the weight gradually increased over time. Biofeedback may be used during Kegel exercises to help engage pelvic floor muscles. Pelvic electrical stimulation helps functioning of the detrusor muscle, relieving incontinence up to 90% of people (O’Shaughnessy). Recently, extracorporeal magnetic resonance therapy, where a magnetic field induces electrical activity in pelvic floor muscles, is being used with some success. Bladder training programs involve a schedule of voiding every 2 hours. The length of time between voiding is gradually increased as the woman learns to maintain control.

Source: Medical Disability Advisor



Complications

Complications may occur as a result damage caused by of backward flow of urine toward the kidneys (ureteral reflux), enlargement of the urinary drainage system (hydronephrosis), bladder or kidney infection, or chronic kidney failure. Perineal skin damage and infection can result without appropriate preventive skin care. Increased risk of falls occurs when women attempt to rush to the toilet. The inability to control urine can interfere with a woman social relationships, work, and sex life. This can lead to social isolation, depression, and disability.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Lifting should be avoided, as should environments that trigger sneezing, coughing, or changing positions too often. Certain noises (e.g., running water) may provoke urination, so workplaces with these noises may need to be avoided. Individuals at work should have easy and regular access to bathroom facilities. Additional work restrictions and accommodations may be needed following bladder neck suspension procedures.

Work restrictions and accommodations also may be needed for surgical correction of other problems that contribute to the incontinence. Restrictions and accommodations may include no heavy lifting, a shorter workday, and time off for follow-up appointments. In some situations, catheters may be placed in the bladder for several days to several weeks following the procedure. Employees returning to work with catheters in place may need accommodations so that the catheter bag can be emptied and the catheter maintained.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Does woman have a history of multiple childbirths?
  • Is woman pregnant?
  • Has woman gone through menopause?
  • Has woman experienced previous pelvic surgery?
  • Is woman taking medications that contribute to incontinence?
  • Has woman been referred to an appropriate specialist (urologist, gynecologist)?
  • Has woman kept a voiding diary to help identify the circumstances that precipitate incontinence?
  • Were any physical abnormalities in the genitourinary system noted on physical exam?
  • Was an urodynamic test performed?
  • Has the type of incontinence been identified?
  • Has the cause of the incontinence been established?

Regarding treatment:

  • Has weight loss or medication been effective in relieving symptoms?
  • Has a long enough trial of medication been done to gauge effectiveness?
  • Has woman been encouraged to perform Kegel exercises to strengthen pelvic floor muscles? Have other strengthening tools been tried?
  • Have other nonsurgical treatments, such as electrical stimulation or biofeedback, been tried?
  • Have exercises or other nonsurgical methods been effective in reducing incontinence?
  • If nonsurgical methods have failed to reduce symptoms, is surgical intervention now warranted?

Regarding prognosis:

  • Based on the type of treatment required, has adequate time elapsed for complete recovery?
  • Have all associated conditions that contribute to the incontinence (e.g., mental health disorders, urinary tract infection, chronic constipation, estrogen deficiency, neurologic disorders) been addressed in the treatment plan?
  • Would woman benefit from consultation with an appropriate specialist (psychiatrist, neurologist, gynecologist)?
  • Is woman an appropriate candidate for surgical intervention?
  • Has woman experienced any associated complications (reflux, bladder or kidney infection, kidney dysfunction, or perineal excoriation) that could affect recovery and prognosis? If so, are these complications being addressed in the treatment plan?

Source: Medical Disability Advisor



References

Cited

Nygaard, Ingrid, et al. "Prevalence of Symptomatic Pelvic Floor Disorders in US Women." JAMA 300 11 (2008): 1311-1316.

O'Shaughnessy, Michael. "Urinary Incontinence, Medical and Surgical Aspects." eMedicine. Eds. Martha K. Terris, et al. 9 Feb. 2007. Medscape. 11 Aug. 2009 <http://emedicine.medscape.com/article/257260-overview>.

Rackley, Raymond, et al. "Urinary Incontinence, Nonsurgical Therapies." eMedicine. Eds. Martha K. Terris, et al. 6 May. 2009. Medscape. 11 Aug. 2009 <http://emedicine.medscape.com/article/452289-overview>.

Vasavada, Sandip P., Maude E. Carmel, and Raymond Rackley. "Urinary Incontinence." eMedicine. 2 May. 2014. Medscape. 3 Jul. 2014 <http://emedicine.medscape.com/article/452289-overview>.

Source: Medical Disability Advisor






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